2020-05-04
Observations from the front line on how we are managing this pandemic
By Dr Jane Ralls, GP in Mt Hawthorn and long-term member of the Greens and the Doctors’ Reform Society
“This article was written on 8th April, and while it is still valid, clearly things have changed daily. It looks like we’ve beaten it in WA if we keep our borders closed (including to and from NSW for now) which is amazing and very cheering. The advantages of being the most isolated city in the world!"
Health is inseparable from Social Justice and Equity, which are the main issues in this pandemic. My remit is to talk about “Health” while the social side will be covered elsewhere. I will talk from my personal perspective as a GP, on one of the front lines, and will do my best not to duplicate what others can say more eloquently.
My greatest hope is that this situation will lead to more equitable, compassionate societies around the world, as we all realise how many people we love are very vulnerable. My fear is that governments will take the opportunity to further erode civil liberties, and slide through climate worsening legislation while people’s minds are occupied elsewhere (the McGowan government has already done that with the Browse Basin gas hub).
I am sure by now that everyone knows about the importance of “physical distancing” (with “social connectiveness”) to “flatten the curve”. “Self Isolation” is quite different and much stricter: it is really just for those with the illness. These measures will prolong the epidemic in Australia, but will allow us to treat everyone according to their needs. The alternative is frankly horrible to even contemplate. Herd immunity is relevant to immunisations: if we apply the concept to infections such as this, an awful lot of lovely people will die. In my mind, we have to wait it out until either a vaccine is available that protects and doesn’t harm us (a project which cannot be rushed) or the virus runs its course and becomes much less virulent (i.e. nasty!) as happened with SARS and MERS.
Walking to work, I pass a number of worksites where physical distancing is clearly not a concept anyone has heard of. I can understand why COVID-19 is affecting social groups inequitably in New York ‒ but this is a social justice issue: back to “health”!
General Practice Reality
A few weeks ago, I saw a lovely young man I had not met before. In my room, after getting through first the nurse on the phone and then the practice manager at the front door who both asked about his travel history, he confided to me that he had a trivial cold and had returned from London within 2 weeks. He said casually: “sorry I got my dates wrong”. His temperature was 37.7 which fitted testing criteria on that day, so I sent him to the COVID clinic, and spent a long time sterilising my room. I am sure he had COVID-19. He wasn’t tested (they don’t take GP referrals) as his temperature was 37.4 when he got there. Two days later my asthma flared up, so I went for testing which was fortunately negative, possibly as I got him out very promptly! The day I saw him, as I predicted, was the day they announced that there is community spread in WA. He clearly was not the only one behaving like that.
Testing
This episode brings up a lot of issues. The first is that we have not been doing anything like enough testing, unlike Singapore and South Korea. If they have had enough reagents, why don’t we? Research elsewhere, which Australia is sadly not contributing to, has shown that 80% of infected people have very mild illness or no symptoms at all. Japan led by testing everyone on that first cruise ship as they disembarked, and found that figure. If we do the maths, and realise we have only been testing very sick people, there must be 5 times as many people infected as we are told. Why can’t we do some trials scattered around the country on pre-school children (children get it but very rarely become ill) and young health workers with no symptoms? I strongly believe that would help us understand the Australian situation much better as time goes on.
Personal Protective Equipment
A second salient point here is about PPE. The Czech Republic may have proven that enforcing masks in public greatly reduces the spread of infection, although surgical masks prevent us from giving it to someone else, not the other way around. I think this is worthwhile! I wear a surgical mask for every patient – but only in case I get it and don’t know yet: I don’t want to pass it on! I was horrified to be tested by a nurse in full PPE but only a surgical mask, instead of a proper P2 or N95 mask to protect her. To have the swabs done (a long and most unpleasant experience BTW!) obviously I had to take off my mask. We will be sacrificing some amazing health care professionals if that continues – young healthy health workers have died from this virus, and must have been exposed to a massive dose. I desperately hope that particular nurse doesn’t become one of them.
I am aware of the world shortage of proper PPE. However, we could all make masks when we go out if we received instruction, although gloves may be at least as useful ‒ full PPE should be reserved for those most at risk, with strict instructions how to use and conserve. In Australia, this has not been done well at this time.
The 80%
The third point from that episode is about young people. Most are responsible and very worried, but some don’t understand that they could have it with no symptoms. I rang my young man a few days later to check he was self-isolating and to recommend 20 days (I’ll come to that). He was amazed when I told him that my patients booked for that afternoon had included one on chemotherapy and one on strong immunosuppression. (This was before the funding of telehealth and both wanted to see me in person). Many healthy people simply have no idea what GPs actually do!
Timing
So why 14 days isolation, when we should be thinking of two different timescales anyway? The average incubation period is 5 days, but it can be as long as 20 days. This is the time from exposure to illness. We also need to know how long symptomatic people should stay isolated, and we are recommending till they are better + 72 hours. But what if there is no illness? Studies elsewhere have shown the illness to last at least a month, but I am not aware of any knowledge of infectivity time for those with trivial or no symptoms. It appears to me that “14 days” was a guess early in the pandemic and has stuck in the government’s rhetoric with no scientific back up.
I do acknowledge the difficult reality of prolonged self-isolation especially for groups such as those in unsafe relationships, extroverts, and for families where a parent is not allowed to even cuddle their kids.
A Seasonal Virus?
As a GP, I get daily updates which I attempt to read. They consist of about 15 links with links within the links. I can’t read all that over breakfast! It’s more use for me to go to work. I have trawled through those links at length when I can though. I am looking for instructions of what to do when what I call the “Snotty Kid Season” arrives. Nothing. Surely the fact that Europe has had winter while the virus has gone rampant is relevant? Our winter is yet to arrive. The rhetoric remains about travellers being the main vectors, although very soon there will be none, and yet the pandemic continues. What if the children, who rarely get sick with COVID-19, are spreading it? I am doing car consults to examine ears, chests and temperatures, but if I suspect tonsillitis I will have to look in their mouths with a tongue depressor and they will cough on me. I’ll wear my mask and goggles (which steam up and I can’t touch them), but there aren’t enough P2 masks for every sick kid. I wish someone would tell me how GPs should manage this situation?
Telehealth
Fortunately, after pressure from many doctor’s groups, Telehealth and telephone consults are now here and funded. For simple issues this is good, and when patients have privacy, good wifi, good video and audio capacity on a device we can do a lot. Unfortunately, there are many difficulties as you can imagine. (Social justice and equity rear their heads again). Privacy at each end is a big issue (I’m not sure how I could work at home and maintain patient confidentiality) – we are all learning new things very fast and it is easy to forget the patient is not in our room alone. “Just a script” actually means a review of the condition. If we forget to check they are alone when we ask questions they are not expecting, there are many risks especially to people in unsafe relationships. Domestic Violence has been discussed, but not Reproductive Coercion. On a lighter note, noisy children demand their parent’s attention when they are on the phone, and a doctor’s appointment is not immune!
I have discovered I hate the phone, especially for mental health, and really need non-verbal cues. A psychologist I work with a lot has a client whose anxiety she can only assess by watching his feet. She at least will continue to see people face to face as long as she is allowed, but many health professionals won’t, and are retreating to safety behind a screen or a phone. Which is better though? I don’t know.
Other illnesses
At the height of the virus in Wuhan, doctors still needed to lay their hands on 50% of patients. This sounds about right to me. Other important illnesses will continue and must not be missed, otherwise we will have a second epidemic of chronic illness “on the other side”. Checking for cancer, monitoring diabetics, heart disease, antenatal care, childhood immunisations and looking for developmental delay are among the many things that we cannot do with telehealth (even for patients with video capability) so it is important that people feel safe to attend GP surgeries. I am quite sure many do not as they don’t know the measures we GPs can take to try to keep the virus out of our rooms. Although, as things progress and winter (eventually) descends, without further help as I mentioned before, I am not sure if we will be able to keep our vulnerable patients safe.
Vaccines
Vaccines are essential especially for the elderly and the immunosuppressed. Covid-19 plus another respiratory infection could be fatal even in the usually healthy. I think most people know everyone should have a flu vaccine this year, although we are awaiting more government funded ones for the under 65s at the moment (who knows when?), and are having to ask people to come back, or to pay. Pneumococcus causes a vaccine-preventable bacterial pneumonia, though it is only funded for the over 65s, and over 50 years for First Nations peoples. There are few private stocks left even for people who can afford them, so what about the highly at risk younger people? I strongly believe this program should be urgently updated. And Pertussis (Whooping Cough) is another, currently only funded for kids and pregnant women. A start, but not enough! Adults are the group who usually get it now, as childhood immunity wears off.
Mental Health
My biggest concerns lie with Mental Health. We are all losing our “lifestyle antidepressants” especially those without a garden. No gym, no meditative 50m pools, crowded and frankly scary parks and supermarkets. Structures and scaffolding carefully put in place to keep people healthy have crumbled extremely rapidly. Will we see an increase in psychotic illness and paranoia as this goes on? Many are losing their jobs and cannot afford medications. Crowded spaces are of extreme concern (prisons, detention centres, hostels and women’s refuges) and I greatly fear for our wonderful elders in remote communities. It would be a terrible tragedy to lose any one of them.
Management in the Community
I am sure the answer lies in bringing people along with kindness, compassion and care for everyone. Insults like our Premier slung at toilet roll hoarders will never work, as any good door knocker knows. People are frightened and need their fear acknowledged. Jacinda Ardern has shown the world how to lead, and bring people with her in hope and togetherness. A couple of days warning before lock down goes a long way, rather than springing change on people unexpectedly and demanding they all comply.
Private Health has no role in treating COVID-19, as the model has never been any use for serious illness, for which team work is essential. Having said that, an enormous amount of tax payers’ money has poured into the private hospitals for many years – I believe now is the time to reclaim it for everyone, and acquire all the Intensive Care facilities for everyone’s use.
Last but foremost we need to care for each other and maintain “social connectiveness”. Check up on everyone we know regularly, and be kind to each other, whatever their political persuasion. I really appreciate the thanks I have had as a front-line health worker – it is lovely to feel so supported. This is a time to work together; by all means criticise corporates who pay no taxes, and private health funds demanding more inappropriate funds, but the individuals who work there are human beings like the rest of us, and we need to tread extremely carefully politically right now. Now is the time to model the world we wish to live in and show the way, so that we don’t return to the destructive old ways when we do reach “the other side”.
Longer term, Climate Change is the greatest concern, and to discover how quickly behaviours can change in an emergency should actually be extremely reassuring for us all.
Header photo: the author with brother and son, taken last year
[Opinions expressed are those of the author and not official policy of Greens WA]